HIV/AIDS Flashcards
1
Q
What group of viruses does HIV belong to?
A
retroviridae group
2
Q
How does the virus replicate within infected host cells?
A
Carries RNA genome and a reverse transcriptase enzyme (RNA-directed DNA polymerase)
3
Q
How does HIV infect cells?
A
Affinity for binding to specific cell surface receptor molecule (CD4+)
4
Q
What cell count do you monitor in HIV to monitor dz progress?
A
CD4+
5
Q
MC mode of infection for HIV
A
sexual transmission across exposed mucosal epithelium
6
Q
Viral pathogenesis
A
~ Proliferation of infected CD4+ T lymphocytes + migration of infected macrophages = appearance of viral RNA in bloodstream
~Widespread secondary amplification of infection within lymphoid tissue of:
- Gastrointestinal tract (Peyer’s patches)
- Spleen
- Bone marrow
7
Q
Viral pathogenesis results
A
- Depression of functional capacity of T lymphocytes
- Depletion of helper T cells
- Impairment of killer T cell action
- Increased suppressor T cells
8
Q
Who should be tested for HIV?
A
- all people 15-65 regardless of risk, at least once
- all pregnant women prior to childbirth
- younger/older individuals with increased risk factors
9
Q
Initial testing of HIV
A
FDA-approved 4th-generation antigen/antibody combination immunoassay – detects HIV-1 & HIV-2 antibodies and HIV-1 p24 antigen
10
Q
What is no longer recommended for HIV testing
A
ELISA, HIV-1 Western blot, and HIV-1 IFA no longer part of recommended algorithm
11
Q
HIV Serology CD4 cell count
A
- The best measure of the status of the immune system and disease progression
- Demonstrates the risk of opportunistic infections
- Helps determine when to start antiretroviral therapy and PCP prophylaxis; also helps in evaluating the immune system’s response to this therapy
- If untreated, CD4 count declines at a rate of approximately 50 cells per year
12
Q
HIV CD4 counts >500 cells
A
- minimal compromise in the immune system and the threat of HIV-related infection or illness is marginal
13
Q
CD4 count 200-500
A
- risk of HIV-related conditions, such as herpes zoster, TB, lymphoma, bacterial pneumonias, and Kaposi sarcoma, increases
14
Q
CD4 count <200
A
- when most of the opportunistic infections that define AIDS present
15
Q
HIV viral load is used to measure…
A
- measure the response to and efficacy of HAART; gives corresponding predictive information to the CD4 count
- If the viral load is still > 50 after 4 months of therapy, regimen modification may be needed
16
Q
Acute infection of HIV
A
- Initially appears with a syndrome similar to that seen with mononucleosis
- Occurs about 2-4 weeks after exposure to HIV
- Sx consistent with flu/mono
- this duration is brief: 3 days to 2 wks
17
Q
ASx/Latent infection of HIV
A
- Seropositive: no Signs/Sx of HIV infection
- Normal CD4 count
- Longest phase: lasting 4-7 yrs
18
Q
Symptomatic infection of HIV
A
- “Pre-AIDS”
- 1st notice of immunocompromised state
- Phase length tends to vary with efficacy of tx and condition of immune system
19
Q
Neurologic Sx of HIV infection symptoms
A
- meningitis
- encephalitis
- peripheral neuropathy
- myelopathy
20
Q
Dermatological Sx of HIV infection symptoms
A
- erythematous maculopapular rash
- mucocuatneous ulceration
21
Q
Sx HIV infection clinical manifestations
A
- Persistent generalized lymphadenopathy
- Localized fungal infections (e.g., onychomycosis, thrush)
- Intractable vaginal yeast and trichomonal infections in females
- Oral hairy leukoplakia on the tongue
- Dermatologic conditions: seborrheic dermatitis, psoriasis exacerbations, molluscum contagiosum, warts
- Constitutional symptoms: night sweats, weight loss, diarrhea
22
Q
Clinical manifestations of AIDS
A
- Marked immune suppression
- Onset of disseminated opportunistic infections and malignancies
- CD4 count < 200/mm3
23
Q
Sexual transmission of HIV
A
- MC mode of transmission
- No cases of transmission from saliva or tears documented
- Highest risk: unprotected anal receptive intercourse
- Latex condoms: reduce risk by 70-80%
- oral sex can result in transmission of HIV/STI’s
24
Q
Needle sharing modes of transmission
A
- Risk of sustaining HIV infection from a needle stick with infected blood = 1 in 300
- Behavior can increase risk (needle sharing, “booting” the injection with blood, and performing frequent injections)
- Crack cocaine use (the injection or smoking) is associated with increased prevalence of HIV infection (cocaine for sex bartering)
- Secondary transmission occurs to children and sexual partners
25
Perinatal transmission of HIV/AIDS
- Vertical transmission: in utero, during childbirth, via breast-feeding
- Without prophylactic treatment, approximately 25% of children born to HIV-infected mothers will contract the disease as well
- 50% risk with prolonged breast-feeding
- Neonatal immune system is immature = increased susceptibility to many infections
- Transmission most commonly occurs during childbirth and early breast-feeding stages
- Worldwide, perinatal transmission = most common method of transmission of HIV to children
26
Occupational exposures of HIV/AIDS
- Needle stick is most common route of occupational exposure
- Thousands of cases studied with 58 cases of well-documented infection reported in US (41% were nurses)
- Risk via this route is low, but every effort should be made to decrease the risk to negligible or zero
- Educational efforts, engineering controls and needled and sharp edged medical devices, use of hard plastic sharps containers, and development of procedural details to avoid blood and body fluid contact all can result in reduced exposure rate
- Basically, use Universal Precautions for everyone
27
Post-exposure Prophylaxis medications
| NOT PReP: pre-exposure
- emtricitabine
- raltegravir
- tenofovir
Start as soon as possible after potential exposure and continue for four weeks.
28
SDE of Nuclesoide Reverse Transcriptase Inhibitors (NRTI)
- BM suppression
- Peripheral neuropathy
- Megaloblastic anemia (ZDV drug)
- Pancreatitis
29
Nuclesoide Reverse Transcriptase Inhibitors (NRTI) drugs
- Abacavir (ABC)
- Didanosine
- Emtricitabine
- Lamivudine
- Stavudine
- Tenofovir
- Zalcitabine
- Zidovudine (ZDV)
30
NonNuclesoide Reverse Transcriptase Inhibitors (NNRTI) drugs
- Efavirenz (contraindicated in pregnancy)
- Nevirapine
- Delavirdine (contraindicated in pregnancy)
31
Toxicity of NonNuclesoide Reverse Transcriptase Inhibitors (NNRTI) drugs
Rash
Hepatotoxicity
CNS sx with efavirenz
32
Protease Inhibitor drugs
all end in -navir
33
Toxicity of Protease Inhibitors
```
Hyperglycemia
Hyperlipidemia
GI intolerance
Lipodystrophy
Crystal induced nephropathy (indinavir)
```
34
One toxicity drug to remember
Crystal induced nephropathy (indinavir - protease inhibitor)
35
Integrase strand transferase inhibitors drug toxocity
hypercholesterolemia
36
Pharmacokineteic goal of antiretroviral therapy
improve efficacy of other antiretroviral agents in a cART regimen; can do so by adding a pharmacokinetic enhancer
37
Brand name atripla has what combo drugs inside?
Efavirenz
Emtricitabone
Tenofovir
38
Brand name truvada has what combo drugs inside?
Emtricitabine
| Tenofovir
39
Deferral of therapy may be considered if...
- High CD4 count (> 500 cells/mcL)
- Difficulty or inability to adhere to therapy
- Presence of comorbidities that would complicate or be a contraindication to antiviral therapy
- Patient considered a long-term non-progressor
40
Initial Combo Antiretrovirals
2 NRTIs
+
1 of either NNRTI, PI, or INSTI
41
TB and HIV
- HIV-positive patients co-infected with tuberculosis have 20-30x greater risk for development of active tuberculosis and subsequent infectious state compared with HIV-negative patients
- Every patient should be screened via purified protein derivative (PPD) at time of diagnosis (regardless of the initial CD4 count)
- Latent TB should be treated aggressively to reduce the potential reactivation of active tuberculosis
42
Opportunistic infections (3) of HIV infected with any CD4 count
- TB
- Oral candidiasis
- Kaposi sarcoma
43
Opportunistic infection (1) of HIV infected with CD4 count <250
- Coccidioidomycosis
44
Opportunistic infection (3) of HIV infected with CD4 count <200
- Bacterial pneumonia
- Pneumocystitis pneumonia
- Isoporiasis
45
Opportunistic infection (1) of HIV infected with CD4 count <150
Histoplasmosis
46
Opportunistic infection (5) of HIV infected with CD4 count <100
- Esophageal candidiasis
- toxoplasmosis
- cryptococcosis
- cryptosporidiosis
- microsporidiosis
47
Opportunistic infection (3) of HIV infected with CD4 count <50
- CMV infections
- Mycobacterium avium complex
- Bacillary angiomatosis
48
Oral candidiasis treatment
Treat with one of the following:
- Oral fluconazole daily x 1-2 weeks
- Nystatin swish and swallow 4-5 times/day x 1-2 weeks
- Clotrimazole troches 4-5 times/day x 1-2 weeks
49
Oral candidiasis v. Oral Leukoplakia
Oral candidiasis scrapes off the tongue
50
Kaposi sarcoma
- An AIDS-defining illness
- Can occur at any CD4 count; most common when < 250
- Cancer caused by human herpes virus 8 (HHV-8)
- Typically presents as red, purple, brown, or black papular lesions on the skin or mucous membranes
- Has a similar appearance as bacillary angiomatosis
51
Pneumocystis Penumonia
- General
- Sx
- Dx
- CXR
- An AIDS-defining illness
- Caused by yeast-like fungus Pneumocystis jiroveci (formerly P. carinii)
- Sx: fever, chills, nonproductive cough, pleuritic chest pain, dyspnea
- Dx: suspected based on symptomology, particularly if low CD4 count
- CXR: normal in early disease; often reveals bilateral, ground-glass, interstitial infiltrates in butterfly or bat wing pattern
52
Prophylaxis PCP coverage
TMP/SMX (initiated when CD4 count < 200)
TMP/SMX is preferred therapy for active disease; prednisone may be added for more severe illness
53
Esophageal Candidiasis:
- General
- Sx
- Dx
- Tx
- Preferred Tx
- Commonly occurs concurrent with oropharyngeal candidiasis (but not always)
- Sx: retrosternal chest pain and pain with swallowing (odynophagia)
- This form of candidal infection more likely with CD4 counts < 100
- Dx: often based on symptomology, confirmed with EGD
- Tx: systemic antifungals
Symptomatic involvement within days of treatment initiation
- Preferred tx: fluconazole (PO or IV) or itraconazole (PO) x 2-3 weeks
54
Prophylatic drug for nearly all the drugs on the PowerPoint
TMP-SMX
55
Toxoplasmosis encephalitis treatment
pyrimethamine and sulfadiazine with leucovorin
56
Cryptococcosis
- General
- Presentation
- Dx
- Tx
- Yeast (Cryptococcus neoformans) causing disseminated disease in immunocompromised individuals
- Often presents as meningoencephalitis or meningitis
- Presentation: fever, malaise, headache (often without photophobia and meningimus)
- Dx confirmed by LP and CSF analysis (increased opening pressure)
- Cryptococcal antigen (CrAg) testing on CSF and serum
- CSF microscopy (w/ India ink): encapsulated, budding yeast
- Treatment regiments using amphotericin B, flucytosine, fluconazole, and/or combinations thereof
57
Difference b/w Cryptococcosis and Cryptosporidiosis
Cryptococcosis: meningitis
Cryptosporidiosis: diarrhea
58
Cryptosporidiosis
- Protozoal infection affecting the small bowel mucosa
- Associated with profuse watery, non-bloody diarrhea with fever and abdominal pain (usually asymptomatic in immunocompetent patients)
- Lower CD4 counts = more severe disease, prolonged duration
- Treatment focuses on improving CD4 counts with ART
- Adjunctive therapy: paromomycin or nitazoxanide
59
CMV infections: retinitis
- Most common presentation of CMV infection
- Two-thirds of cases are usually unilateral
- Vision changes, loss of peripheral vision, scotoma, and/or floaters
60
CMV infections: esophagitis
- Presents with chest pain, odynophagia, and nausea
| - EGD: ulcerations in distal esophagus, biopsies to confirm dx
61
Women living with HIV infection
- AIDS is 9th leading cause of death in women 35-44 years of age in United States
- Fourth leading cause of death in African American women (same age group)
- Women account for nearly 50% of all AIDS cases worldwide and 20% of those in the United States (as of 2014)
- Partly due to the receptive intercourse effects
- cART appears more effective in preventing opportunistic infections and disease progression among women
- However, increased likelihood of toxicities among women than in men
62
Women: general effects from HIV
- present with AIDS usually at a higher CD4 level
- worse prognosis than men (big factor = socioeconomic factors)
- less access to healthcare (diagnosis late in the game), domestic violence, homelessness, lack of community support
63
Gender specific findings in women with HIV disease
- Irregular menstruation
- Recurrent vulvovaginal candidiasis
- Human papillomavirus-related cervical dysplasia (abnormal, pre-malignant cell proliferation)
- Invasive cervical cancer and other HPV-associated neoplasia
64
cART therapy and pregnant women
Initiation of cART is recommended for HIV-positive pregnant women in all stages of pregnancy
65
Most common route for infection of children
transplacental
66
Elderly people with HIV
- Approximately 16.5% of new cases in 2014 were in people > 50 years of age
- Nearly ¼ of patients with HIV/AIDS are > 50 years of age
- Not uncommon for this population to be less knowledgeable about HIV and prevention strategies
67
Increased incidence of HIV/AIDS in elderly populations is likely because of...
- Divorces and death of spouse
- Erectile dysfunction medications
- Contraception no longer a concern postmenopause
- Vaginal atrophy = small cuts and tears = increased blood exposure
- Less discussion during encounters with PCPs
68
PrEP AIDS prevention
Truvada (emtricitabine/tenofovir DF)
69
Patients considered for PrEP
- Sexually active homosexual and bisexual men
- Male-to-female transgender persons
- Heterosexual and bisexual women who are likely to have partners with HIV risks
- Injection drug users
70
Factors that increase the likelihood that PrEP is a good option
- Patient has receptive anal intercourse
- has a known HIV-infected partner
- history of sexually transmitted infections
- a high number of sex partners
- commercial sex workers
- inconsistent or no condom use
- sharing needles or related paraphernalia (“works”)
71
Initial assessment before Rx PrEP
- HIV antibody test: confirm HIV negative status
- Symptom review to exclude HIV infection (e.g., no history of acute illness with fever and rash in prior month)
- Check other STD tests
- Check renal function: SCr & eGFR
- HBV vaccine/confirm immunity
72
What to discuss with them about PrEP
- Is not 100% effective
- Does not protect against other STDs
- May have side effects
- Should still use latex condoms/clean needles
- Adhere to drug every day
- HIV antibody testing every 3 months, SCr every 6 months, and other tests to maintain health
73
Topical microbicides of HIV/AIDS
Chemical barrier to impede viral transmission/inactivate the virus before crosses vaginal/rectal membranes
- 1% vaginal gel containing tenofovir: showed a 54% decrease in incidence of HIV infection
